Diabetic Wounds

Diabetic wounds are a major problem for modern day health care.  The foot is the most common site of infection in the diabetic and is the number one reason for hospital admission in diabetic patients.  The annual cost of foot care is in excess of $15 billion and 25% of the 11 million Americans with diabetes will develop foot problems.  One in 15 will require an amputation.  The amputation rate in diabetics is six per 1,000 patients and account for 50-75% of all amputations done in each year in the US.  There were 152,000 amputations done in the US in 1986. Ten percent of these surgeries resulted in the loss of a foot, 35% in the loss of a lower leg, and 30% lost the knee joint.  Higher amputation occurs in 24% of the cases.  After an amputation, diabetic patients have a 50% survival rate three years post surgery.

Diabetic wounds were approved for coverage under Medicare in 2003.  Wounds that benefit the most from HBOT are where the blood supply has been damaged, there is swelling and/or infection, or in wounds where the immune system is not functioning properly.

Diabetic ulcers are extremely expensive.  In 1985 reimbursement for diabetic foot complication permitted only ten days of hospitalization at $731 per day, for a total reimbursement of $3,748.  The average stay in the hospital for treatment for diabetic foot infections is 22-36 days, at a cost of at least $5,000 to $7000.  These costs do not reflect outpatient expenditures.

In 2005, Kranke et al systematically reviewed HBO and chronic wounds, based on publications from 1966 too 2003, including five randomized controlled trials (RCT).43 In diabetic foot ulcers HBOT significantly reduced the incidence of amputation. One leg amputation was avoided per four patients treated with HBOT.

In 2007 the Canadian Agency for Drugs and Technology in Health reported in “Adjunctive HBOT for Diabetic Foot Ulcer” that the economic benefit of avoiding major amputations significantly lowered treatment costs: $40,695 HBO vs. $49,786 for standard care.44

(Note: Dermagraft is a cryopreserved human fibroblast-derived dermal substitute composed of fibroblasts, extracellular matrix, and a bioabsorbable scaffold.  Dermagraft is used in the treatment of full-thickness diabetic foot ulcers greater than six weeks duration. Circulator Boot Corporation provides a product used in limb salvage.)

The cost of one amputation is reported to be in excess of $40,000.  Medicare reimbursement is approximately $12,500.  Hospitalization averages about 40 days.  Subsequently, six to nine months of rehabilitation may be needed.  Many of these patients are elderly and remain wheelchair-bound for the rest of their lives.  The estimated direct cost of amputation is in excess of $1.5 billion yearly.  Readmission within two years for stump modification or more amputation costs another $1 billion yearly.  Many of these patients are unable to go back to work and require public assistance.

The physiological benefits of HBOT are improved oxygenation of the threatened margins of wounds, generation of granulation tissue (the collagen matrix for wound healing), enhanced phagocytosis (white blood cells eating damaged tissue and bacteria) and killing of microorganisms, enhanced antibiotic penetration, and improved wound healing with increased rate of fibroblast collagen production that supports capillary angiogenesis (new growth).  The direct bacteriostatic effect of HBOT on anaerobic microorganisms is particularly beneficial.

Notes
43I. Roeckl-Wiedman, M. Bennet, P. Krank, Systemic review of hyperbaric oxygen in the management of chronic wounds. Br J Surg 2005; 92: 24-32.
44CADTH (Canadian Agency for Drugs & Technology in Health) Technology Overview Report. Overview of adjunctive hyperbaric oxygen therapy for diabetic foot ulcer. Issue 25. March 2007.